HIV Case Manager - Street Team Medicine

Position Description:

The Street Medicine HIV Case Manager is a key member of the Street Medicine multidisciplinary team responsible for delivering intensive, field-based case management, counseling, and care coordination services to individuals living with HIV who are experiencing homelessness or housing instability.

This role supports Medical Care Coordination (MCC) and Ending the HIV Epidemic (EHE) program goals by improving linkage to care, retention in care, and viral suppression outcomes. The Case Manager / Counseling Navigator assumes primary responsibility for patient tracking, follow-up, care coordination, and interdisciplinary communication to ensure continuity of care across highly transient populations with complex medical, behavioral health, and substance use needs.

Principal Responsibilities

• Conduct comprehensive biopsychosocial assessments with emphasis on HIV care engagement, treatment adherence, and barriers to care.
• Serve as the primary case manager for HIV-positive patients engaged through Street Medicine, maintaining active patient panels and tracking care status.
• Identify, locate, and re-engage patients who are out of care, lost to follow-up, or non-adherent to treatment.
• Develop, implement, and monitor individualized care plans aligned with MCC and EHE program requirements.
• Coordinate linkage to HIV medical care, including intake, follow-up appointments, lab completion, and medication access.
• Track and follow all HIV-positive patients to support continuity of care, viral suppression, and treatment adherence.
• Provide HIV counseling, adherence counseling, harm reduction education, and risk-reduction interventions to support engagement in care and viral suppression.
• Coordinate referrals for specialty care, behavioral health, substance use treatment, housing navigation (including interim housing, permanent supportive housing, and recuperative care), and other social services.
• Assist patients with housing navigation, including completing applications, gathering required documentation, coordinating with housing partners, and supporting placement into appropriate housing programs.
• Monitor and follow up on labs, referrals, and treatment plans, ensuring timely completion and appropriate follow-through.
• Communicate patient status, barriers, and urgent needs to providers in real time to support timely intervention and care decisions.
• Participate in daily team huddles to review patient needs, prioritize outreach, and coordinate field activities.
• Participate in multidisciplinary case conferences with providers, Program Managers, behavioral health teams, and external partners.
• Conduct intensive field-based outreach across encampments, shelters, interim housing sites, and mobile units.
• Utilize tracking tools (e.g., REDCap, registries, internal logs) to monitor patient engagement, outcomes, and follow-up needs in accordance with program requirements.
• Complete accurate, timely, and audit-ready documentation in NextGen and required reporting systems (e.g., ACMS CaseWatch, Formsite).
• Maintain active tracking systems for high-risk and complex patients, including those with co-occurring medical, behavioral health, and substance use conditions.
• Submit regular summaries of care coordination activities, patient trends, and identified needs to support reporting and continuous quality improvement.
• Assist with field readiness, including coordination of supplies, logistics, and patient care needs during outreach activities.
• Support Medical Assistants and outreach staff by reinforcing workflows, assisting with care coordination processes, and contributing to training and competency development.
• Collaborate closely with providers, Program Managers, ECM teams, and community partners to ensure coordinated and efficient service delivery.
• Assist patients with insurance enrollment, benefits navigation, and access to Ryan White and other HIV-related services.
• Provide patient-centered counseling and navigation services consistent with HIV Counseling and Testing and Ryan White program expectations.
• Maintain compliance with all JWCH policies, grant requirements (HRSA, EHE, HHIP), and regulatory standards.
• May drive a company vehicle to transport staff, supplies, and patients, as required, to support field operations and ensure access to care.
• Perform other duties as assigned.

Requirements / Essential Skills

• Bachelor's Degree in Social Work, Psychology, Public Health, Human Services, or related field from an accredited institution required. Master's Degree preferred.
• Minimum of three (3) years of experience working with HIV-positive populations, case management, or high-risk underserved populations required.
• Demonstrated experience performing intensive case management, including patient tracking, care coordination, follow-up, and navigation of medical and social service systems.
• Demonstrated knowledge of HIV care continuum, treatment adherence, and Ryan White program expectations.
• Strong understanding of co-occurring conditions, including mental health and substance use disorders.
• Experience working with individuals experiencing homelessness or housing instability strongly preferred.
• Ability to manage complex patient panels and coordinate care across multiple systems.
• Strong organizational, time management, and critical thinking skills.
• Ability to work independently in field-based environments and as part of a multidisciplinary team.
• Strong interpersonal and engagement skills with high-acuity, transient populations.
• Knowledge of HIPAA and patient confidentiality requirements.
• Experience with electronic health records and tracking/reporting systems.
• Valid California driver's license, clean driving record, and ability to operate a company vehicle.

Relevant experience may be considered in lieu of formal education on a year-for-year basis.

Preferred Qualifications

• Experience with Ryan White, MCC, EHE, or other HIV grant-funded programs.
• Familiarity with NextGen, REDCap, ACMS CaseWatch, and population health tools.
• Experience in Street Medicine, mobile health, or field-based outreach programs.
• Bilingual in Spanish preferred.
• Knowledge of local housing systems and community resources.
• Experience working with dual-diagnosed populations (mental health and substance use).

Work Environment

This position is primarily field-based and operates in encampments, shelters, interim housing sites, recuperative care settings, and mobile medical units. The role requires flexibility, adaptability, and the ability to work in physically and emotionally demanding environments with highly transient populations.

• All JWCH, Wesley Health Centers workforce members are recommended to be fully vaccinated against COVID-19.

Employee Benefits:

At JWCH Institute, Inc., we believe in taking care of those who take care of others. If you work 30+ hours per week, you'll enjoy competitive pay and a robust benefits package that includes:

• Medical, Dental, Vision
• Monthly employer-sponsored allowance for assistance with health premiums.
• Funded Health Savings Account (up to deductible) to assist with carrier-approved medical expenses.
• Paid time off (vacation, sick leave) and 13 paid holidays.
• 401(k) Safe Harbor Profit Sharing plan.
• Mileage reimbursement.
• Short- and long-term disability plans (LTD/STD).
• Life insurance policy & AD&D, and more!

Become part of a team where your work matters. Apply today and help us change lives, one patient at a time.

JWCH Institute, Inc + Wesley Health Centers is an Equal Opportunity and Fair Chance Employer.